1. by Scott Cerreta, BS, RRT Director of Education www.copdfoundation.org Expectations after Pulmonary Rehabilitation

2. Conflict of Interest I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.

3. Objectives 1.Discuss current literature and outcomes after pulmonary rehabilitation. 2.Identify key elements that must be maintained after pulmonary rehabilitation. 3.Learn about the COPDF Pulmonary Education Program (PEP) as a post-graduation program. 4.Understand circumstances that lead to post-graduation loss of benefits gained during rehab.

4. Literature Review Long term effectiveness (>2years) of Pulmonary Rehabilitation is disappointing Drop-off is multifactoral Two most significant factors 1.Exacerbations of COPD 18 2.Decrease in adherence to exercise prescription 18 AACP/AACVPR Pulm Rehab Clinical Practice Guidelines suggests that PRCs include strategies to promote long-term adherence 1

5. Literature Review MT group had improved ESWT No influence on QoL or hospital admissions Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and health status in patients with COPD. JCRPJournal; 47-52.

6. Maintaining Benefits after Rehabilitation 1.Encourage participation in Phase III rehab – Unproven health advantages long term for: Continuous PR Maintenance PR programs Repeated courses of PR – Cost prohibitive in current health care system 2.Prevent Hospitalizations – Recognition of early signs of infection 3.Continue exercises at home or gym 4.Teach Optimal Care

7. Optimal Care Includes: 1.Smoking cessation 2.Pulmonary rehabilitation – Exercise and nutrition – Recognize early signs of infection – Breathing techniques – Coping skills – End-of-Life care 3.Annual spirometry on a good day 4.Testing for Alpha-1 Antitrypsin Deficiency 5.Medication adherence

9. FEV 1 / FVC < 70% I: Mild FEV 1 >80% pred II:Moderate FEV 1 50-80% pred III: Severe FEV 1 30-50% pred IV: Very Severe FEV 1 < 30% pred or FEV 1 <50% predicted plus respiratory failure Active Reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators: ß 2 agonists and anticholinergics Add rehabilitation Add ICS for repeated exacerbations Add LTOT Surgical interventions GOLD Standards of COPD Care http://www.goldcopd.org/

10. The Problem with Rehab ??? No one remembers to order it ! Recommended for GOLD Stage II Only 16% of physicians send patients to Rehab Rehab is your key resource to improve patient adherence and understanding of this disease

11. Maintaining Benefits after Rehabilitation Optimal Care must be maintained lifelong Encourage participation in Phase III Find other programs and resources to offer your patients after graduation – Develop local programs for transitional care – Collaborate with other organizations Local home care companies, not DME State Smokers’ Quit Line COPD Foundation

12. New Programs for the COPD Foundation 1.Healthy Interactions Conversation Map – Designed for acute care / transitional care setting – Education to decrease hospitalization and teach patient self-management 2.Pulmonary Education Program (PEP) – Designed for pulmonary rehabilitation centers – Prolong benefits of rehab by connecting patients to COPD Foundation resources after graduation.

13. Healthy Interactions Conversation Map ® Pulmonary education not rehab – Designed for acute care admission for COPD patient – Hospital to Home transitional care program – Small group participation 6-10 – Facilitator navigates patients through a conversation map educational tool. Patient makes own decisions Patient learns from others experiences Patient learns to self-manage and become active in care – We are still recruiting partner sites! – Final Map tool used for Rehab Recruitment – Future role-out to clinics, hosp, home care, etc.

14. All tools developed by Healthy Interactions. Conversation Map® is a registered trademark of Healthy Interactions, Inc.

15. Pulmonary Education Program (PEP) Designed for Pulm Rehab – Promotes long-term benefits after rehab Sit and Be Fit Exercise DVD Access to COPDF Resources Access to COPD Info Line Follow-up Program with Rehab Center Enhance Patient Support Groups Host COPD Education Day events

16. C.O.P.D. Information Line 1-866-316-COPD (2673) Provides empathy and support to callers, as well as access to resources (e.g. educational materials) Info Line associates are people with COPD New branch staffed by associates offer support and information for caregivers www.copdfoundation.org Additional COPD Resources at Your Lung Health http://www.yourlunghealth.org/lung _disease/copd/resources/index.cfm

17. COPD Research Registry Aims to build the proper cohort of patients to enroll in clinical trials and studies Over 2,600 patients enrolled Online/paper enrollment forms Info available through Info Line Created to help increase enrollment in COPDGene Study National Jewish Health is data coordinating center www.copdfoundation.org

18. BFRG Ver2.0 Modeled after the Alphanet BFRG for Alpha-1 Most comprehensive guide on COPD health management Over 70 individuals and organizations contributed www.copdbfrg.org www.copdfoundation.org

19. SSRGs 1.Coping with COPD 2.End-of-Life 3.Exacerbations 4.Exercise 5.Medicine 6.Nutrition 7.Oxygen Therapy 8.Travel 9.Understanding Lung Disease 10.Understanding Tests www.copdfoundation.org

20. Summary Teach optimal care Keep patients involved with lifelong care Know your patients – What stage COPD – Encourage spirometry annually – Encourage patients learn their FEV1 and stage Collaborate with others to maintain long term benefits of pulmonary rehabilitation End result is decreased hospitalizations and improved patient outcomes.

22. References 1.Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR evidence based clinical practice guidelines. Chest 2007;131;4S-42S 2.Ries AL, Make BJ, Lee SM, et al. The effects of pulmonary rehabilitation in the National Emphysema Treatment Trial. Chest 2005; 128:3799–3809 3. Cambach W, Wagenaar RC, Koelman TW, et al. The long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive disease: a research synthesis. Arch Phys Med Rehabil 1999; 80:103–111 4.Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000; 355:362–368 5.Troosters T, Gosselink R, Decramer M. Short- and longterm effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Am J Med 2000; 109:207–212 6.Foglio K, Bianchi L, Ambrosino N. Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study. Chest 2001; 119:1696–1704 7.Finnerty JP, Keeping I, Bullough I, et al. The effectiveness of outpatient pulmonary rehabilitation in chronic lung disease: a randomized controlled trial. Chest 2001; 119:1705– 1710 8.Ries AL, Kaplan RM, Myers R, et al. Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial. Am J Respir Crit Care Med 2003; 167:880–888 9.Guell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: a randomized trial. Chest 2000; 117:976–983 10.Griffiths TL, Phillips CJ, Davies S, et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001; 56:779–784

23. References 11.Wijkstra PJ, van der Mark TW, Kraan J, et al. Long-term effects of home rehabilitation on physical performance in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996; 153:1234–124 12.Engstrom CP, Persson LO, Larsson S, et al. Long-term effects of a pulmonary rehabilitation programme in outpatients with chronic obstructive pulmonary disease: a randomized controlled study. Scand J Rehabil Med 1999; 31:207–213 13.Wijkstra PJ, TenVergert EM, van Altena R, et al. Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease. Thorax 1995; 50:824–828 14.Berry MJ, Rejeski WJ, Adair NE, et al. A randomized, controlled trial comparing long-term and short-term exercise in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 2003; 23:60–68 15.Puente-Maestu L, Sanz ML, Sanz P, et al. Long-term effects of a maintenance program after supervised or self- monitored training programs in patients with COPD. Lung 2003; 181:67–78 16.Grosbois J-M, Lamblin C, Lemaire B, et al. Long-term benefits of exercise maintenance after outpatient rehabilitation program in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil 1999; 19:216– 225 17.Cockram J, Cecins N, Jenkins S. Maintaining exercise capacity and quality of life following pulmonary rehabilitation. Respirology 2006; 11:98–104 18.Brooks D, Krip B, Mangovski-Alzamora S, Goldstein RS. The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. Eur Respir J 2002; 20: 20–29. 19.Ringbaek T, Brondum E, Martinez G, et al. Long-term effects of 1-year mainenance training on physical functioning and health status in patients with COPD. JCRPJournal; 47-52. 20.COPD Foundation. www.copdfoundation.org